Fundamentals Ch. 37 (Kozier)

The nurse is preparing a 23-year-old female client for surgery. The nurse should anticipate which diagnostic test to be prescribed for this client? 1. Pregnancy test 2. EEG 3. EKG 4. Pulmonary function tests

Correct Answer: 1 Rationale 1: A pregnancy test is done on all female clients of childbearing age. Rationale 2: An electroencephalogram is not considered a routine preoperative diagnostic test. Rationale 3: An electrocardiogram is done on all clients over 40 years of age and/or clients with preexisting cardiac conditions. Rationale 4: Pulmonary function tests are not routine preoperative diagnostic tests.

A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. What should the nurse respond? 1. These exercises help prevent pneumonia. 2. The doctor ordered the exercises. 3. All surgical clients must do these exercises. 4. These exercises prevent thrombophlebitis.

Correct Answer: 1 Rationale 1: By increasing lung expansion and preventing accumulation of secretions, deep breathing helps prevent pneumonia and atelectasis. Rationale 2: These are nursing interventions and do not need to be prescribed by a physician. Rationale 3: Although this may be true, it does not instruct the client as to the purpose of the exercises. Rationale 4: Turning, deep breathing, and coughing exercises do not prevent thrombophlebitis.

The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis? 1. Leg exercises 2. Coughing every 2 hours 3. Ambulating every 2 hours 4. Oxygen by mask

Correct Answer: 1 Rationale 1: Leg exercises may be implemented in the PACU to help prevent thrombophlebitis. Rationale 2: Coughing every 2 hours does not prevent thrombophlebitis. Rationale 3: Ambulation is not done in the postanesthesia care unit. Rationale 4: Oxygen does not prevent thrombophlebitis.

The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which assessment should the nurse perform first? 1. Level of consciousness 2. Dressing 3. Drains 4. Skin color

Correct Answer: 1 Rationale 1: The nurse should assess the clients level of consciousness first. Rationale 2: The operative dressing is not assessed first. Rationale 3: Any operative drains are not assessed first. Rationale 4: The clients skin color is not assessed first.

The nurse is preparing to conduct preoperative teaching. What should be included in this teaching? 1. Information related to what will happen to the client 2. Referral of the client to the physician for any misconceptions the client may have 3. The role of the nurse during surgery 4. How to perform activities of daily living (ADLs) following surgery

Correct Answer: 1 Rationale 1: The nurse should provide information related to what will happen to the client, when, and what the client will experience. Rationale 2: The nurse should clarify any misconceptions the client may have. Rationale 3: The nurse should also explain the roles of the client and support people in preoperative preparation, during the surgical procedure, and during the postoperative phase. Rationale 4: How to perform ADLs following surgery is not a part of preoperative teaching.

The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk for which reason? 1. The physiological deficits of aging increase the surgical risk for older adults. 2. The older adult has increased kidney function. 3. The older adult has an increase in sensory function. 4. The older adult will turn, cough, and deep-breathe more effectively.

Correct Answer: 1 Rationale 1: The older adult has more physiological deficits, such as decreased kidney function and decreased thirst, and is at greater risk for fluid and electrolyte imbalances. Rationale 2: The older client has decreased kidney function. Rationale 3: The older client has a decline in sensory functioning. Rationale 4: The older client may not be able to follow directions or understand instructions as well as a younger client.

The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse should document that the client is in which operative phase? 1. Preoperative phase 2. Intraoperative phase 3. Postoperative phase 4. Perioperative phase

Correct Answer: 1 Rationale 1: The preoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the operating table. Rationale 2: The intraoperative phase begins when the client is transferred to the operating table and ends when the client is admitted to the PACU. Rationale 3: The postoperative phase begins with the admission of the client to the postanesthesia area and ends when healing is complete. Rationale 4: There is not a specific perioperative phase of surgical care. Perioperative care consists of three phases: preoperative, intraoperative, and postoperative.

During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do? 1. Coach the client to deep-breathe and cough. 2. Restrict fluids. 3. Remind the client to perform leg exercises. 4. Maintain on bed rest.

Correct Answer: 1 Rationale 1: The reduction of breath sounds could indicate the pooling of secretions in the lower lobes. The nurse should coach the client to deep-breathe and cough. Rationale 2: Restricting fluids could cause the pulmonary secretions to thicken, making them more difficult for the client to cough and remove. Rationale 3: Leg exercises will not improve breath sounds. Rationale 4: Bed rest will not improve the clients breath sounds.

The nurse is planning a perioperative clients needs upon discharge. What should be included when determining these needs? Standard Text: Select all that apply. 1. Clients abilities to provide self-care 2. Date of anticipated discharge 3. Physician performing the surgery 4. Financial resources 5. Need for home health care services

Correct Answer: 1, 4, 5 Rationale 1: Discharge planning incorporates an assessment of the clients abilities for self-care. Rationale 2: Discharge planning does not include the clients anticipated date of discharge. Rationale 3: Discharge planning does not include the name of the physician performing the surgery. Rationale 4: Discharge planning incorporates an assessment of the clients financial resources. Rationale 5: Discharge planning incorporates an assessment of the clients need for home health care.

The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain? Standard Text: Select all that apply. 1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment 5. Maintain NPO status

Correct Answer: 1, 2, 3, 4 Rationale 1: A brief or mini mental status examination provides valuable baseline data for evaluating the clients mental status and alertness after surgery. It is also important to evaluate the clients ability to understand what is happening. Rationale 2: Assessment of hearing helps guide the effectiveness of perioperative teaching. Rationale 3: Respiratory assessment not only provides baseline data for evaluating the clients postoperative status but may alert care providers to a problem that may affect the clients response to surgery and anesthesia. Rationale 4: The gastrointestinal status provides baseline data. Rationale 5: Maintaining NPO status is a nursing intervention. It is not included in the physical assessment.

The nurse is obtaining preoperative assessment data. What should be included in this assessment? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Mothers maiden name

Correct Answer: 1, 2, 3, 4 Rationale 1: The clients current health status should be obtained when completing a preoperative assessment. Rationale 2: The clients allergies should be obtained when completing a preoperative assessment. Rationale 3: The clients current medications should be obtained when completing a preoperative assessment. Rationale 4: The clients mental status should be obtained when completing a preoperative assessment. Rationale 5: The mothers maiden name is not a part of a preoperative assessment.

The nurse has removed the sutures from a clients surgical wound. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Number of sutures removed 2. Appearance of the incision 3. Client teaching 4. Client tolerance of the procedure 5. Name of the surgeon

Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse should document the number of sutures removed. Rationale 2: The nurse should document the appearance of the incision. Rationale 3: The nurse should document any client teaching. Rationale 4: The nurse should document the clients tolerance of the procedure. Rationale 5: The nurse does not need to document the name of the surgeon.

The nurse is completing a preoperative assessment with a client. What should this assessment include? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Respiratory rate

Correct Answer: 1, 2, 3, 4 Rationale 1: When documenting the current health status, essential information includes general health status and the presence of any chronic diseases that might affect the clients response to surgery or anesthesia. Rationale 2: When documenting allergies, the nurse should include allergies to prescription and nonprescription drugs, food allergies, and allergies to tape, latex, soaps, or antiseptic agents. Rationale 3: All current medications should be listed. Herbal remedies and over-the-counter preparations are also a part of this assessment. Rationale 4: The clients current mental status is a part of this assessment. Rationale 5: Respiratory rate is part of the physical assessment.

A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this clients degree of risk for this major surgical procedure? Standard Text: Select all that apply. 1. Age 2. Medications 3. General health 4. Blood pressure 5. Nutritional status

Correct Answer: 1, 2, 3, 5 Rationale 1: The degree of risk involved in a surgical procedure is affected by the clients age. Rationale 2: The degree of risk involved in a surgical procedure is affected by the clients use of medications. Rationale 3: The degree of risk involved in a surgical procedure is affected by the clients general health. Rationale 4: Blood pressure is not identified as specifically impacting the degree of risk when having a surgical procedure. Rationale 5: The degree of risk involved in a surgical procedure is affected by the clients nutritional status.

The nurse is preparing to instruct a client on leg exercises to be used when recovering from abdominal surgery. What should the nurse determine before beginning this teaching? Standard Text: Select all that apply. 1. Type of surgery 2. Time of surgery 3. Postoperative diet 4. Preoperative orders 5. Name of the surgeon

Correct Answer: 1, 2, 4, 5 Rationale 1: Before beginning to teach leg exercises, the nurse needs to determine the type of surgery. Rationale 2: Before beginning to teach leg exercises, the nurse needs to determine the time of the surgery. Rationale 3: The clients postoperative diet is not a consideration prior to completing teaching on leg exercises. Rationale 4: Before beginning to teach leg exercises, the nurse needs to determine preoperative orders. Rationale 5: Before beginning to teach leg exercises, the nurse needs to determine the name of the surgeon.

The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals? Standard Text: Select all that apply. 1. Maintain the sterile field. 2. Perform instrument counts. 3. Instruct in postoperative exercises. 4. Position the client appropriately for surgery. 5. Perform preoperative skin preparation.

Correct Answer: 1, 2, 4, 5 Rationale 1: Maintaining the sterile field will support the goals of maintaining client safety and homeostasis. Rationale 2: Performing instrument counts will support the goals of maintaining client safety and homeostasis. Rationale 3: Instructing in postoperative exercises will not support the goals of maintaining client safety and homeostasis. Rationale 4: Positioning the client appropriately for surgery will support the goals of maintaining client safety and homeostasis. Rationale 5: Performing preoperative skin preparation will support the goals of maintaining client safety and homeostasis.

A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include which information? Standard Text: Select all that apply. 1. The time suction was started 2. Characteristics of wound drainage 3. Pressure on the suction 4. Integrity of the surgical dressing 5. Color and consistency of drainage

Correct Answer: 1, 3, 5 Rationale 1: For the nasogastric tube placed to suction, the nurse should document the time suction was started. Rationale 2: The characteristics of the wound drainage are not related to the nasogastric tube suction. Rationale 3: For the nasogastric tube placed to suction, the nurse should document the pressure on the suction. Rationale 4: The integrity of the surgical dressing is not related to the nasogastric tube suction. Rationale 5: For the nasogastric tube placed to suction, the nurse should document the color and consistency of the drainage.

The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present? 1. Absence of bleeding 2. Edges warm to the touch 3. Edges well approximated 4. Sutures in place

Correct Answer: 2 Rationale 1: Absence of bleeding is an indication of healing. Rationale 2: If the wound becomes warm, red, and edematous, the nurse should suspect an infection and notify the physician. Rationale 3: Edges that are well approximated are an indication of healing. Rationale 4: Intact sutures are a sign of healing.

The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery? 1. Ineffective Protection 2. Risk for Aspiration 3. Impaired Skin Integrity 4. Risk for Falls

Correct Answer: 2 Rationale 1: Although this diagnosis is appropriate for a client having surgery, the nurse should prioritize care according to the ABCs, or airway, breathing, and circulation, when planning care. Rationale 2: This is the priority nursing diagnosis for the client having surgery. The risk for aspiration would impact the clients airway and breathing. Rationale 3: Although this diagnosis is appropriate for a client having surgery, the nurse should prioritize care according to the ABCs, or airway, breathing, and circulation, when planning care. Rationale 4: This nursing diagnosis is not appropriate during the intraoperative phase of care.

The nurse is preparing to apply antiembolic stockings to a postoperative client. What should be done first, before applying the stockings? 1. Measure the calf. 2. Assess for circulatory problems. 3. Assess the clients blood pressure. 4. Clean the stockings.

Correct Answer: 2 Rationale 1: Measuring the calf is the first step of implementing antiembolic stockings. Rationale 2: Before applying antiembolic stockings, determine any potential or present circulatory problems and the surgeons orders involving the lower extremities. Rationale 3: Assessing the blood pressure is not done before applying antiembolic stockings. Rationale 4: The client should be given clean stockings, but the nurse should not have to wash stockings before using.

The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching this client? 1. Pamphlets 2. Play 3. Books 4. Videotapes

Correct Answer: 2 Rationale 1: Pamphlets would be appropriate to supplement instruction to an adult or older client. Rationale 2: Play is an effective teaching tool with children. Rationale 3: Books would be more appropriate to supplement instruction to a school-age child. Rationale 4: Videotapes would be appropriate for adolescent or adult clients

The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal of care for this client? 1. Provide necessary preoperative teaching. 2. Assist the client to achieve the most optimal health status possible. 3. Ensure client safety. 4. Maintain an aseptic environment.

Correct Answer: 2 Rationale 1: Providing necessary preoperative teaching is an activity associated with the preoperative phase. Rationale 2: The goal of postoperative care is to assist the client to achieve the most optimal health status possible. Rationale 3: Ensuring client safety is a goal of the intraoperative phase. Rationale 4: Maintaining an aseptic environment is an action within the intraoperative phase.

A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia? Standard Text: Select all that apply. 1. The client remains conscious. 2. Respiratory rate can be regulated easily. 3. It is used for minor surgical procedures. 4. The anesthesia can be adjusted to the length of the operation. 5. It focuses on a single nerve or nerve group.

Correct Answer: 2, 4 Rationale 1: The clients remaining conscious is an advantage of regional anesthesia. Rationale 2: An advantage of general anesthesia is that the respiratory rate can be regulated easily. Rationale 3: Regional anesthesia is used for minor surgical procedures. Rationale 4: An advantage of general anesthesia is that the anesthesia can be adjusted to the length of the procedure. Rationale 5: A nerve block focuses on a single nerve or nerve group.

The nurse is planning to remove the sutures from a clients surgical wound. What should the nurse do before removing the sutures? Standard Text: Select all that apply. 1. Apply clean gloves. 2. Verify the order for suture removal. 3. Ambulate the client to the bathroom. 4. Read the order to determine whether a dressing is to be applied after removal. 5. Remove the dressing and clean the incision.

Correct Answer: 2, 4, 5 Rationale 1: The nurse is to apply sterile gloves for suture removal. Rationale 2: Before removing skin sutures, the nurse should verify that there is an order for suture removal. Rationale 3: The client is not to be ambulated to the bathroom for suture removal. Rationale 4: Before removing skin sutures, the nurse should verify whether a dressing is to be applied following the suture removal. Rationale 5: Before removing skin sutures, the nurse should remove the dressing and clean the incision.

A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is 1. diagnostic. 2. palliative. 3. ablative. 4. constructive.

Correct Answer: 3 Rationale 1: A diagnostic surgery is done to confirm or establish a diagnosis. Rationale 2: Palliative surgery is done to relieve or reduce pain or symptoms of a disease. The surgery does not cure an illness. Rationale 3: When the purpose of surgery is ablative, the diseased body part is removed. Rationale 4: Constructive surgery restores function or appearance that has been lost or reduced.

The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client? 1. Self-Care Deficit 2. Disturbed Body Image 3. Ineffective Airway Clearance 4. Risk for Falls

Correct Answer: 3 Rationale 1: After surgery, a client may have a self-care deficit; however, this is not the priority. Rationale 2: Depending upon the type of surgery, the client may have disturbed body image; however, this is not the priority. Rationale 3: When prioritizing, the nurse should remember the ABCs. Airway should always be the priority. Rationale 4: A client recovering from surgery may be at risk for falls; however, this is not the priority.

The nurse is caring for a client in the recovery area. In which position should the nurse place the unconscious client during the immediate postanesthesia phase? 1. Supine 2. Prone 3. Side-lying 4. Supine with a pillow under the head

Correct Answer: 3 Rationale 1: In the supine position, the client could occlude the airway. Rationale 2: In the prone position, the clients operative site may not be readily assessed. Rationale 3: The unconscious client should be positioned on the side, with the face slightly down. Rationale 4: A pillow under the head could cause the clients airway to become obstructed

The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective? 1. The lower extremity is swollen and hot to touch. 2. The vein feels hard. 3. There is no cramping or pain with ambulation. 4. There is pain in the calf with dorsiflexion.

Correct Answer: 3 Rationale 1: Lower extremity swelling and heat would indicate the presence of thrombophlebitis. Rationale 2: A hard vein would indicate the presence of thrombophlebitis, and that leg exercises were not effective. Rationale 3: The absence of cramping or pain with ambulation indicates that leg exercises instructed prior to surgery were effective to prevent the onset of thrombophlebitis. Rationale 4: Pain in the calf with dorsiflexion would indicate the presence of thrombophlebitis, and that leg exercises were not effective.

The nurse is preparing the skin of a client for surgery. The nurse knows the purpose of the surgical skin preparation is to 1. sterilize the skin. 2. assess the surgical site before surgery. 3. reduce the risk of postoperative wound infection. 4. clean any moles the client may have.

Correct Answer: 3 Rationale 1: The preparation of the skin prior to surgery is not to sterilize the skin. Rationale 2: The purpose of a surgical skin preparation is not to assess the surgical site before surgery. Rationale 3: The purpose of a surgical skin preparation is to reduce the risk of postoperative wound infection. Rationale 4: The purpose of a surgical skin preparation is not to clean any moles the client may have.

The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement? 1. Place the stethoscope over the stomach and listen for a swishing sound while inserting water into the tube. 2. Place the stethoscope over the stomach and listen for a swishing sound while inserting air into the tube. 3. Aspirate stomach contents and check the acidity using a pH test strip. 4. Connect the tube to suction and observe the contents.

Correct Answer: 3 Rationale 1: Water should not be inserted into the tube until placement is confirmed. Rationale 2: This is done to ensure placement; however, it is not the most reliable test. Rationale 3: Aspirating stomach contents and checking the acidity using a pH test strip is the most reliable test to confirm tube placement. Rationale 4: Connecting the tube to suction should not be done until tube placement has been confirmed.

The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery. What did the nurse assess to make this clinical decision? 1. Abdominal distention present. 2. Gas pains present. 3. Client vomiting. 4. Bowel movement occurred 24 hours after resuming a normal diet.

Correct Answer: 4 Rationale 1: Abdominal distention is an indication of postoperative constipation. Rationale 2: Gas pain is an indication of postoperative constipation. Rationale 3: Vomiting is an indication of postoperative constipation. Rationale 4: A bowel movement that occurs within 48 hours after resuming a normal diet is evidence that postoperative constipation has been prevented

The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the clients risk of this postoperative complication? 1. Administer an anticoagulant. 2. Assist the client to cough every 2 hours. 3. Monitor intake and output every 2 hours. 4. Provide for early ambulation.

Correct Answer: 4 Rationale 1: Anticoagulant therapy must be prescribed by a physician. Rationale 2: Coughing every 2 hours will reduce the clients risk of developing pneumonia or atelectasis. Rationale 3: Measuring intake and output every 2 hours assesses the clients renal function. Rationale 4: Early ambulation, leg exercises, antiembolic stockings, SCDs, and adequate fluid intake are all interventions to reduce the risk for thrombophlebitis.

The nurse is preparing a client for an upper GI endoscopy. For which type of anesthesia should the nurse prepare the client to receive? 1. Local anesthesia 2. Spinal anesthesia 3. Epidural anesthesia 4. Conscious sedation

Correct Answer: 4 Rationale 1: Local anesthesia is used for minor surgical procedures such as suturing a small wound or performing a biopsy. Rationale 2: Spinal anesthesia is used for surgeries such as hernia repairs, rectal surgeries, or cesarean sections. Rationale 3: Epidural anesthesia is the introduction of an anesthetic into the epidural space. Rationale 4: Conscious sedation is often used for procedures such as endoscopies and incision and drainage of abscesses.

The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel? Standard Text: Select all that apply. 1. Clean the wound. 2. Assess the skin around the wound. 3. Determine the effectiveness of pain medication. 4. Report if the dressing is soiled. 5. Report if the dressing is loose.

Correct Answer: 4, 5 Rationale 1: Cleaning a newly sutured wound, especially one with a drain, requires application of knowledge, problem solving, and aseptic technique. This procedure should not be delegated to UAP. Rationale 2: The nurse is responsible for assessment of the wound. Rationale 3: The nurse is responsible for evaluation of medication provided. Rationale 4: The nurse can ask the UAP to report soiled dressings that need to be changed. Rationale 5: The nurse can ask the UAP to report if the dressing is loose and needs to be reinforced

The nurse is preparing to change the dressing on a clients postoperative wound. Place in order the steps the nurse should perform when removing the soiled dressing. Standard Text: Click and drag the options below to move them up or down. Choice 1. Assess the location, type, and odor of wound drainage. Choice 2. Remove the outer dressing. Choice 3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves. Choice 4. Remove the under dressing. Choice 5. Apply clean gloves. Choice 6. Place the soiled dressing in a moisture-proof bag.

Correct Answer: 5, 2, 6, 4, 1, 3 Rationale 1: Once the under dressing is removed, the nurse should assess the location, type, and odor of any wound drainage. Rationale 2: The nurse should then remove the outer dressing. Rationale 3: The nurse should then discard the under dressing in a moisture-proof bag and remove and discard the gloves. Rationale 4: The nurse should next remove the under dressing. Rationale 5: The nurse first should apply clean gloves. Rationale 6: The nurse should place the soiled outer dressing in a moisture-proof bag.